My thoughts on flibanserin (which is NOT the female “Viagra”)

I meant to write this a few weeks ago after my ode to Smitten Kitchen. My goal is to pair pieces with more substance with short blurbs on things that interest me, but alas life got busy and I am only getting to it now.

A short disclaimer: this topic may be a sensitive one. I am definitely open to debate but please do so in a respectful manner. I am looking at this issue as both a scientist and feminist. I think a thorough understanding of both viewpoints is essential to move forward in the field of increasing female sexual desire.

So, let’s begin. First of all, you may be saying to yourself – what in the world is Kassey talking about? I’ll give you a short introduction to the subject. I think we have all heard of Viagra (generic name: sildenafil) – not only are we inundated with commercials but it’s definitely found a place in pop culture (“Love and Other Drugs”, anyone?) Developed by Pfizer in the 90’s, Viagra was originally conceived to treat hypertension. It works at the cellular level, resulting in dilation of blood vessels and increased blood flow. In early clinical trials, the effects of this increased blood flow were most evident in the penis, stimulating an erection. Pfizer then decided to market the drug to treat male erectile dysfunction, and it became one of their “blockbuster” drugs, bringing in billions of dollars over the years.

For the past 20 years, there has been considerable interest in creating the female equivalent of Viagra, but this endeavor has not had the same success. The drug that has come the closest to FDA approval is flibanserin (Sprout Pharmaceuticals). Flibanserin has been submitted for approval several times; but the first few times the FDA requested further clinical trials. Most recently an FDA panel recommended approval of the drug, meaning that approval is most likely imminent.

A tablet of flibanserin sits on a brochure for Sprout Pharmaceuticals (Source: Time.com)

As mentioned above, Viagra acts by stimulating increased blood flow to the penis, result in an erection when a man is sexually aroused. It works in most men on the first or second use.

In contrast, flibanserin was originally developed as an antidepressant. but was observed to increase female libido, in some cases. It’s mechanism of action is to interact with receptors in the brain, regulating levels of neurotransmitters and hormones. Unlike Viagra, it only works in a select population of women (less than 10%). In clinical trials, it resulted in on average one more sexually satisfying experience per month – this is hardly comparable to the effectiveness observed with Viagra. Furthermore, flibanserin was associated with several adverse effects, such as sleepiness, dizziness, nausea, fatigue, and upper respiratory tract infections. It may also impair one’s ability to drive. When choosing to prescribe a medication such as this, physicians often weigh the balance of the benefits vs. the side effects with the patients. In my opinion, most patients will think this ratio is negligible compared to that of Viagra.

Even the Score campaign – Is the FDA biased against women?

There are 2 dominant feminist viewpoints in the discussion surrounding flibanserin. The first is that emulated by the Even the Score campaign. The mandate of the website, www.eventhescore.org, is to “serve as a voice for American women who believe that it is time to level the playing field when it comes to the treatment of women’s sexual dysfunction”.

I’m definitely all for the same availability to means of increasing female sexual desire as men, but I think that Even the Score’s campaign negates the fact that female sexuality is more complex than men’s and as it stands currently, cannot be fixed with a pill. This may be a bold statement, however, I am not saying that men’s sexual dysfunction can always be fixed by medication such as Viagra, nor should be. I am a strong advocate of medical solutions when necessary. If a male’s issues with sex are caused by other physiologic or psychologic conditions; this should not be ignored. However, I am also a strong believe in statistics and here the numbers don’t lie: study after study shows that men orgasm significantly more often than women and, as mentioned above, Viagra is effective in most men upon first use.

Now, some women may have a medical condition formerly known as hypoactive sexual desire disorder (HSDD); in the most recent revamp of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (basically the bible for psychiatrists and psychologists), this disorder was eliminated and the DSM-5 now includes a disorder called sexual interest/arousal disorder, designed to more accurately reflect the complexity of women’s sexual experience. It is these women that would be the target population for women with flibanserin and the population the FDA would approve its use in.

Considering the complexity of female sexuality, it is no wonder that there are no approved drugs to treat it. It is not as simple as giving Viagra to stimulate an erection. We don’t even know exactly what causes female hyposexuality in women, so how can we treat it with a medication if we don’t know what to target? Furthermore, the FDA has strict guidelines and regulations concerning drug approvals. There rigorous requirements for clinical trials for a drug to gain approval and it is practically impossible for emotional biases to affect an approval, and nor should they. Campaigns such as Even the Score are dangerous – pressuring a body to approve a drug because it is “time for it” could lead to the approval of a drug that is unsafe or dangerous for those that use it.

Why should women have to take a pill? Maybe the problem is with their partner?

Another argument is that there should be no medical interventions to boost a female libido and that focusing on these drugs takes away from focusing on other issues, such as a partner that is not fulfilling their needs or underlying emotional or psychological issues. I wholeheartedly agree that sexuality is complex and cannot be fixed by a simple pill. I think that this issue can be likened to anxiety and depression; antianxiety medication or antidepressants do not cure these illnesses nor do they work in every single individual. However, we cannot discount their benefits in some subsets of the population. Speaking from personal experience, some people need a “boost” before they can be even amenable to therapy. There may be a subset of women who would benefit from a drug such as flibanserin, in combination with other nonpharmacologic methods to boost their libido. Like antidepressants, women should work with their doctor to find a solution that is right for them. I agree that antidepressants may be overprescribed, and we could see the same problem with drugs to treat female sexual dysfunction. However, we should encourage more complete and thorough evaluations for these drugs, rather than dismiss them entirely.

To finish, I believe there is a place for medical treatments of female sexual dysfunction; however, I don’t think flibanserin is it. I am curious to see how this field develops over the next few years.

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2 thoughts on “My thoughts on flibanserin (which is NOT the female “Viagra”)”

Interesting read! I would argue though that women’s sexuality isn’t more or less complex than men’s. There are two components to sexuality, the psychological arousal and the physiological response. Equating Viagra to Flibanserin is comparing two completely different aspects of the sexual experience. It’s easy enough to treat a physiological dysfunction such as ED, but trying to induce psychological arousal when its lacking is complicated – in men and women. I’m sure there are men who have a low sex drive that’s unrelated to their ability to maintain an erection and I wonder if something like Flibanserin could be useful for that group aswell.

Also, it may be true that statistically men orgasm more than women, but I also wonder if that’s an inherent difference between the sexes or if it’s due to the fact that female sexuality has been much more taboo. Male masturbation is much more acceptable, while female masturbation is still widely considered shameful. This is reflected in pop culture, where a women masturbating receives much harsher ratings in TV and movies than much more explicit male masturbation. This is a pretty good read about it.

So I guess what I’m saying is maybe women are just as sexual and able to orgasm as men, but have been conditioned to fear their own sexuality at a young age, making it hard for them to truly explore their body unabashedly. At the end of the day you need to know your own body to use it to its full potential. And its not just masturbation, its much less acceptable for a woman to explore her sexuality with partners. So maybe its not a question of female versus male complexity or innate ability to orgasm more frequently but rather a question of making it more acceptable to talk about the mechanics of women’s sexuality openly and honestly. It’s not to say women don’t have sexual dysfunctions- they absolutely do- I just don’t think its fair to use that particular statistic to build the case that women’s sexuality is more or less complex.

And in any case, I don’t know if frequency of orgasm is even a good measure of overall sexual satisfaction.

Thanks Panda for your insightful comment. I think that we can agree that Viagra is treating the physiologic component of sex, whereas flibanserin is psychological. There is really no equivalent for Viagra in women – and there may never be due to the inherent differences in the female vs. male reproductive system.

I’ll definitely have to read a bit more on the psychological components, so thank you for giving me some good starting off points.